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The correlation between civility, respect and patient safety

April-May 2017

It pays to be nice, or to put it more eloquently – to be civil. While it may be a cliché, it does have multiple benefits: it’s good for you, enhancing your influence and performance, and good for your patients. I have come across a few articles of late that reinforce this thinking. The first, “Respect, Patient Safety and Team Work,” by Hein Stander, the President of the Association of Salaried Medical Specialists (ASMS), was published in their October magazine last year, while another article is by a group of Harvard Medical School doctors and researchers who suggest the safest hospitals are those that “reveal certain common cultural characteristics: shared core values of transparency, accountability, and mutual respect.” Showing respect is even more powerful, being respectful doesn’t just benefit you; it benefits everyone around you and may be the most influential behaviour to model to others. (I would certainly recommend you read this article if you’re interested in this topic).

What I found most surprising was the observation that health professionals, including doctors, often model the exact opposite behaviours of incivility and disrespect; for example, not introducing themselves to patients or their relatives. “It’s rare for a healthcare professional to be outright rude, but things like sitting when your patient is sitting, taking the time to explain things thoroughly, or making eye contact don’t happen as often as they should,” says Orly Avitzur, M.D, a Consumer Reports medical adviser.

Lack of courtesy and respect can cause trouble for both the patient and the doctor. We are all aware of medical error, which in the US is thought to be the third leading cause of death. Patients who felt disrespected had twice the error rate of those who felt respected. Why? Most probably due to a lack of engagement. For the patient, to quote again from a consumer publication: “Patient engagement is such a powerful tool that it has been nicknamed “the blockbuster drug of the century.”  So, if you are able to look at including the patient in the team. The NZSA’s December magazine has an article by a Canadian patient advocate who describes the need to shift to a team based approach so that healthcare is patient-led throughout the patient’s perioperative journey.

Engagement is linked to the performance of the individual doctor and the team. Research in this area is somewhat limited but suggests that those who are engaged tend to make fewer errors. Conversely, lack of engagement is associated with negative outputs. The opposite end of the engaged spectrum is burnout, which is characterised by cynicism, exhaustion, and inefficacy. We all experience these at times, but if they are predominant then performance is adversely affected and by inference from the above, the error and complication rate increases, spilling over into our relationships with patients, colleagues and family.

What is engagement? Intuitively we all recognise it, or the lack of it, but officially how do we define it? The NHS has done a lot of work in this area and has provided this definition: “A measure of how people connect in their work and feel committed to their organisation and its goals. People who are highly engaged in an activity feel excited and enthusiastic about their role…devote extra time to the activity and describe themselves to others in the context of their task.”

A definition from an organisational psychology point of view includes high level concepts:

  • Proactive behaviour
  • Personal initiative
  • Psychological engagement
  • Positive representation of organisation to outsiders
  • Organisational citizenship.

Citizenship is an interesting concept. Jefferey Plagenhoef, the current ASA USA President, talks about professional citizenship and sets a high bar for ASA members to meet. I think we often forget that citizenship is a two-way street – it comes with privileges but also responsibilities. Dr Google has the following to say on citizenship:

“Stay informed of the issues affecting your community. Respect and obey the law. Respect the rights, beliefs and opinions of others. Pay income and other taxes honestly and on time….”

For us at the coal face it looks more like staff involvement in decision making or at the very least, open and robust communication and some input into change management.

How can we know if we are engaged or not? I think a simple test is to ask yourself if you are adding value to your daily work, and value to your patient’s journey and that of the institution you work for. By value I mean more than simply inducing anaesthesia and delivering the patient to PACU. Another good question is: “Do I enjoy what I do and do I make my work place better?” This topic may appear to be bordering on warm fuzzy behavioural science type rubbish, but that does not mean that it is not relevant to you; in fact, we may be a group at risk. I refer you to an article in NZSA’s April magazine by our trainee rep Morgan Edwards about the high rate of depression and suicide among anaesthetists. Rather sobering and most of us will know of colleagues who have sadly felt there was no alternative.

Another reason to reflect on being respectful and engaged, and the effect this has on performance and patient outcomes, is that of recertification. The MCNZ takes the ongoing competence of New Zealand doctors very seriously. On your behalf, both NZSA and ANZCA-NC have written submissions in response to the MCNZ’s proposals to strengthen the recertification process. In essence, the proposals are very similar to our current CPD programme and involves audit, feedback from colleagues and resultant CPD plan to demonstrate ongoing, continuous improvement.

Revalidation or recertification are big issues worldwide which many jurisdictions are grappling with. One of the major drivers is to prevent and to identify poorly performing practitioners. Overall, we think the suggested approach by MCNZ is reasonable but have suggested a few tweaks that you are welcome to read. (Read our submission here).

A risk factor for poorly performing doctors is isolation. A particular risk is the older, isolated practitioner – if working as a solo practitioner in rural NZ we have a perfect storm. If one strips away the jargon from the document, the bottom line is the need to optimise patient outcomes; and the need for continuous professional development for doctors to enhance engagement and respect, and ultimately our value.

As always, may the force be with you.



Employee engagement and NHS performance, Michael A West and Jeremy F Dawson

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